Section R4-17-206. License Renewal

A.      To renew a license, a licensee shall submit a completed appli- cation to the Board that includes:

1.        An application form that contains the licensee’s:

a.        First and last names and middle initial;

b.         Arizona license number;

c.          Office, mailing, e-mail, and home addresses;

d.         Office, mobile, and home phone numbers;

2.        A questionnaire that includes answers to the following since the last renewal date:

a.        Whether the licensee has had an application for a certificate, registration, or license refused or denied by any licensing authority, and if so, an explanation;

b.        Whether the licensee has had the privilege of taking an examination for a professional license refused or denied by any entity, and if so, an explanation;

c.        Whether the licensee has voluntarily surrendered a health care professional license, and if so, an expla- nation;

d.        Whether the licensee has had a health professional license suspended or revoked, or whether any other disciplinary action has been taken against a health professional license held by the licensee, and if so, an explanation;

e.        Whether the licensee is currently under investigation by any health profession regulatory authority, healthcare association, licensed health care institu- tion, or there are any pending complaints or disci- plinary actions against the applicant, and if so, an explanation;

f.         Whether the licensee has had any action taken against the applicant’s privileges, including termina- tion, resignation, or withdrawal by a health care institution or health profession regulatory authority, and if so, an explanation;

g.        Whether the licensee has had a federal or state authority take any action against the license’s authority to prescribe, dispense, or administer con- trolled substances including revocation, suspension, denial, or whether the applicant surrendered such authority in lieu of any of these actions, and if so, an explanation;

h.        Whether the licensee has been charged with, con- victed of, pleaded guilty to, or entered into a plea of no contest to a felony or misdemeanor involving moral turpitude or has been pardoned or had a record expunged or vacated, and if so, an explanation;

i.         Whether the licensee has been court-martialed or discharged other than honorably from any branch of military service, and if so, an explanation;

j.         Whether the licensee has been involuntarily termi- nated from a health professional position with any city, county, state or federal government, and if so, an explanation;

k.        Whether the licensee has been convicted of insur- ance fraud or a state or the federal government has sanctioned or taken any action against the licensee, such as suspension or removal from practice, and if so, an explanation;

3.        Consistent with the Board’s statutory authority, such other information as the Board may require to fully evalu- ate the licensee;

4.        A dated and sworn statement by the licensee verifying that during the past state fiscal year the licensee com- pleted a minimum of 20 hours of Category I continuing medical education required by A.R.S. § 32-2523;

5.        The fee required in R4-17-204; and

6.        A confidential questionnaire that includes answers to the following:

a.        Whether the licensee, since the last renewal date, has been diagnosed with or treated for bi-polar disorder, schizophrenia, paranoia, or any other psychotic dis- order, and if so, an explanation;

b.        Whether the licensee is currently being treated or has been treated since the last renewal date for sub-

stance use disorder or participated in a rehabilitation program, and if so, an explanation that includes:

i.         The name of each health professional or health care institution that addressed the substance use disorder and a discharge summary that includes progress; or

ii.        A copy of the confidential agreement or order issued by a health professional or health care institution, if applicable; and

c.        Whether the licensee currently has any disease or condition including a behavioral health illness or condition, substance abuse disorder, physical disease or condition that interferes with the licensee’s ability to perform health care tasks authorized by A.R.S. § 32-2531 and if so, an explanation.

B.       The Board may randomly select a number of statements of completion of continuing education to verify the accuracy of the statements and the acceptability of the Category I continu- ing medical education attended. Physician assistants whose statements have been selected shall submit any additional information requested by the Board to assist in the verifica- tion.

Historical Note

Adopted effective April 22, 1998 (Supp. 98-2). Amended by final rulemaking at 18 A.A.R. 2123, effective October 7, 2012 (Supp. 12-3).